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Phone 877. 448. 3627 If after-hours ask for the infusion nurse on call Fax completed form to 866-507-1164 INFUSION ORDERS ENTYVIO vedolizumab Date of referral Patient Name Date of Birth Address City State ZIP Code Phone WT kg HT in Diagnosis Allergies TB Test Results ICD 10 CODE Please include supporting clinical documentation for specified ICD 10 Code as well as demographic and insurance information. This must be provided to ensure payment by insurance carrier. Please fax with this order...

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